Antipsychotics are a class of drugs used to manage symptoms in people with bipolar disorder. Doctors may prescribe them for use alone or in combination with a mood stabilizer. Sometimes, they are prescribed with an antidepressant. Some are approved to treat acute (severe) mania or depression. Others are approved for maintenance (long-term) therapy.1
How do antipsychotics work?
Each antipsychotic drug works in a slightly different way in the brain. Doctors do not always know exactly how or why these drugs help someone manage their moods. Antipsychotics change the way chemical messengers (neurotransmitters) work in the brain. Dopamine and serotonin are examples of neurotransmitters often affected by antipsychotics.3-13
Examples of antipsychotic drugs
There are many antipsychotic drugs approved to treat symptoms of bipolar disorder. The antipsychotics commonly prescribed for bipolar disorder include:2-12
- Aripiprazole (Abilify®, Aristada®)
- Asenapine (Saphris®, Secuado®)
- Cariprazine (Vraylar®)
- Lumateperone (Caplyta®)
- Lurasidone (Latuda®)
- Olanzepine-fluoxetine (Symbyax®)
- Quetiapine (Seroquel®)
- Risperidone (Risperdal®, Perseris®)
There are no studies that tell doctors which medicine will work best for which patient. Your doctor will work with you to find the medicines that work to manage your bipolar symptoms and provide the best quality of life.5
Aripiprazole
Aripiprazole is used to treat many mental health conditions. It may be prescribed for acute manic or mixed episodes alone or when used with lithium or valproate. It also may be prescribed for maintenance therapy.6
Asenapine
Asenapine may be used to treat many mental health conditions, including acute manic or mixed episodes and maintenance therapy for adults with bipolar 1. It is prescribed in combination with lithium or valproate. It may also be used for acute mania of bipolar 1 in children 10 to 17 years old.7
Cariprazine
Cariprazine is approved for episodes of both bipolar mania and bipolar depression in adults. At lower doses, it does not seem to cause the weight gain and fatigue of other antipsychotics. However, it can cause movement side effects and distressing restlessness or fidgeting (akathisia).8
Lumateperone
Lumateperone is approved to treat bipolar depression in adults. It may be used alone or with the mood stabilizers lithium or valproate.3
Lurasidone
Lurasidone is approved for bipolar depression in people 12 years and older. It has not been studied in treating mania. A small study also found that it may help improve thinking and concentration (cognition) in people with bipolar disorder.1,9
Lurasidone is another antipsychotic that does not seem to cause as much weight gain and fatigue as other antipsychotics.9
Olanzapine-fluoxetine
Olanzapine and fluoxetine are used together to treat acute bipolar depression. Olanzapine does not treat depression by itself, so the antidepressant fluoxetine is added. However, antidepressants are known to trigger mania or mixed episodes or make those symptoms worse.10
Quetiapine
Quetiapine is effective for mixed mania, episodes of acute depression, and long-term maintenance. It also helps with anxiety and insomnia. Quetiapine is not approved for use in people age 10 and younger.11
Risperidone
Risperidone is another antipsychotic prescribed for many mental health conditions. It treats adults with acute manic and mixed episodes of bipolar. It also is used for maintenance therapy.12
What are the possible side effects?
Side effects can vary depending on the specific drug you are taking. Common side effects of antipsychotics include:2-13
- Unwanted movements or tremors (tardive dyskinesia or extrapyramidal symptoms)
- Fatigue, drowsiness, or sleepiness
- Restlessness or agitation
- Nausea, vomiting, constipation, or stomach pain or upset
- Increased appetite
- Weight gain
- Dry mouth
- Drooling
- Sexual difficulties
- Stuffy or runny nose
- Dizziness
Aripiprazole, cariprazine, lumateperone, lurasidone, olanzapine-fluoxetine, and quetiapine have a boxed warning, the strictest warning from the US Food and Drug Administration (FDA). They have this warning because:3,6,8-11
- They come with an increased risk of stroke and death when given to elderly people who have dementia-related psychosis. This is why the drug is not approved for treating dementia-related psychosis.
- They have been linked in a higher risk of suicidal thoughts and suicide in children, teens, and young adults.
Asenapine and risperidone also have a boxed warning from the FDA. They have this warning because they come with an increased risk of stroke and death when given to elderly people who have dementia-related psychosis.7,12
These are not all the possible side effects of antipsychotics. Talk to your doctor about what to expect when taking antipsychotics. You also should call your doctor if you have any changes that concern you when taking antipsychotics. Sometimes side effects can be reduced by lowering the dose or switching to a different drug.13
Other things to know
Antipsychotics should be taken consistently, according to your doctor’s instructions. You should not stop taking any antipsychotic suddenly and avoid missed doses. This can cause unwanted reactions.13
Anyone taking an antipsychotic drug should be watched closely for behavior changes and signs of suicidal thoughts and behaviors.3,6-12
Not all antipsychotics are safe to take while pregnant or breastfeeding. Talk with your doctor about how to manage your pregnancy while staying as mentally healthy as possible. There is some evidence that being off all medicines while pregnant increases the risk of bipolar episodes, which is also a risk to the mother and baby.2
Before beginning treatment for bipolar disorder, tell your doctor about all your health conditions and any other drugs, vitamins, or supplements you take. This includes over-the-counter drugs.